Medicare risk plans have "lock-in" requirements. This means that you generally must receive all covered care through the plan or through referrals from the plan. If you receive services that are not authorized by the plan, neither the plan nor Medicare will pay.
The only exceptions recognized by all Medicare-contracting plans are for emergency services, which you may receive anywhere in the United States, and for services you urgently need when you are temporarily out of the plan's service area.
A third exception offered by some risk plans is called the "point of service" (POS) option. Under the POS option, the plan permits you to receive certain services outside the plan's provider network and the plan will pay a percentage of the charges. In return for this flexibility, expect to pay at least 20 percent of the bill.
Medicare cost plans do not have "lock-in" requirements. If you enroll in a cost plan, you can either go to health care providers affiliated with the plan or go outside the plan. If you go outside the plan, the plan probably will not pay but Medicare will.
If you go outside of the plan, Medicare will pay its share of approved charges. You will be responsible for Medicare's coinsurance, deductibles and other charges, just as if you were receiving care under the fee-for-service system.
Because of this flexibility, a cost plan may be a good choice for you if you travel frequently, live in another state part of the year, or want to use a doctor who is not affiliated with a plan.
The information above summarizes general employee benefit provisions. It is not intended to specify details of any particular employer's plan, nor is it a guarantee of benefits. Contact your benefit representative about specific details regarding your company's employee benefit plan.